This study has been supported by the Discovery Research Grant (B.-J.F.) and the PsA Diagnostic Test Grant (B.-J.F. and J.A.W.) from the National Psoriasis Foundation, and the Utah Genome Project Partnership Grant (B.-J.F. and J.A.W.) and the Immunology, Inflammation, &#38; Infectious Disease (3i) Initiative Seed Grant (B.-J.F. and J.A.W.) from the University of Utah. The author would like to thank Tyler S. Nelson (Physician Assistant, University of Utah Department of Dermatology) and Angela Contreras (Study Coordinator, University of Utah Department of Dermatology) for recruiting patients for the study.

This study was approved by the University of Utah Institutional Review Board (IRB_00137694). Twenty-seven psoriasis patients at the University of Utah dermatology clinic were enlisted to complete a questionnaire about psoriasis severity at the time of the questionnaire&#39;s administration. All patients provided informed consent and completed the questionnaire without instructions from research or medical personnel, either before or immediately after the dermatologist&#39;s assessment.
1. Procedure for making a Psoriasis Thickness Reference Card
<ol>
	<li>Print the Psoriasis Thickness Reference Card template (Supplemental Figure S1) on a standard piece of printer paper. If a printer is not accessible, manually write down the numbers as in the template on any paper and follow the subsequent steps.</li>
	<li>Place sticky notes.
	<ol>
		<li>Purchase a package of sticky notes. The smallest-sized sticky notes (5.08 cm height x 5.08 cm width or 5.08 cm height x 3.81 cm width) will work. The thickness of each sticky note should be between 0.09 and 0.1 mm. 
		NOTE: The authors have tested multiple brands of sticky notes (see Table of Materials) in the market and found that they all fulfill this requirement. If in doubt, one can calculate the thickness of each page by dividing the total thickness of a stack of sticky notes by the number of pages in the stack.</li>
		<li>Place a stack of three sticky notes on the box labeled &#34;3.&#34;</li>
		<li>Place a stack of 5 sticky notes on the box labeled &#34;5.&#34;</li>
		<li>Place a stack of 8 sticky notes on the box labeled &#34;8.&#34;</li>
		<li>Place a stack of 10 sticky notes on the box labeled &#34;10.&#34;</li>
		<li>Place a stack of 13 sticky notes on the box labeled &#34;13.&#34;</li>
	</ol>
	</li>
	<li>Align the adhesive side of the sticky notes on the left side of each corresponding box and press them down to adhere each stack firmly to the sheet of paper.</li>
	<li>Apply a strip of tape along the right side of each stack of sticky notes (Figure 1). Ensure the tape adheres smoothly, creating a gentle slope between the top of the stack and the paper. 
	NOTE: If the left side of each stack is not adhered securely to the paper via the sticky note adhesive, tape the left side in the same way as the right side.</li>
</ol>
2. Usage of the Psoriasis Thickness Reference Card
<ol>
	<li>Slide a finger across the taped side of each stack of sticky notes to get a sense of its thickness or elevation from the paper it is adhered to.</li>
	<li>In a similar manner, slide a finger across the edge of one&#39;s thickest psoriasis patch, feeling its elevation from the surrounding, unaffected skin.</li>
	<li>Identify the stack that is most similar in elevation to one&#39;s thickest psoriasis patch and record the corresponding score of 0 to 13.</li>
</ol>

Development and Evaluation of a Self-Assessment Tool for Psoriasis Severity

<ol>
	<li>Merola, J. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incidence+and+prevalence+of+psoriatic+arthritis+in+patients+with+psoriasis+stratified+by+psoriasis+disease+severity:+Retrospective+analysis+of+an+electronic+health+records+database+in+the+United+States.">Incidence and prevalence of psoriatic arthritis in patients with psoriasis stratified by psoriasis disease severity: Retrospective analysis of an electronic health records database in the United States.</a> Journal of the American Academy of Dermatology. 86 (4), 748-757 (2022).</li><li>Eder, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+incidence+and+risk+factors+for+psoriatic+arthritis+in+patients+with+psoriasis:+a+prospective+cohort+study.">The incidence and risk factors for psoriatic arthritis in patients with psoriasis: a prospective cohort study.</a> Arthritis &amp; Rheumatology. 68 (4), 915-923 (2016).</li><li>Haroon, M., Gallagher, P., FitzGerald, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+delay+of+more+than+6+months+contributes+to+poor+radiographic+and+functional+outcome+in+psoriatic+arthritis.">Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis.</a> Annals of the Rheumatic Diseases. 74 (6), 1045-1050 (2015).</li><li>Belman, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Psoriasis+characteristics+for+the+early+detection+of+psoriatic+arthritis.">Psoriasis characteristics for the early detection of psoriatic arthritis.</a> The Journal of Rheumatology. 48 (10), 1559-1565 (2021).</li><li>Tey, H. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Risk+factors+associated+with+having+psoriatic+arthritis+in+patients+with+cutaneous+psoriasis.">Risk factors associated with having psoriatic arthritis in patients with cutaneous psoriasis.</a> The Journal of Dermatology. 37 (5), 426-430 (2010).</li><li>Rouzaud, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+there+a+psoriasis+skin+phenotype+associated+with+psoriatic+arthritis?+Systematic+literature+review.">Is there a psoriasis skin phenotype associated with psoriatic arthritis? Systematic literature review.</a> Journal of the European Academy of Dermatology and Venereology JEADV. 28, 17-26 (2014).</li><li>Gladman, D. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+and+initial+validation+of+a+screening+questionnaire+for+psoriatic+arthritis:+the+Toronto+Psoriatic+Arthritis+Screen+(ToPAS).">Development and initial validation of a screening questionnaire for psoriatic arthritis: the Toronto Psoriatic Arthritis Screen (ToPAS).</a> Annals of the Rheumatic Diseases. 68 (4), 497-501 (2009).</li><li>Tom, B. D. M., Chandran, V., Farewell, V. T., Rosen, C. F., Gladman, D. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Validation+of+the+Toronto+Psoriatic+Arthritis+Screen+Version+2+(ToPAS+2).">Validation of the Toronto Psoriatic Arthritis Screen Version 2 (ToPAS 2).</a> The Journal of Rheumatology. 42 (5), 841-846 (2015).</li><li>Husni, M. E., Meyer, K. H., Cohen, D. S., Mody, E., Qureshi, A. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+PASE+questionnaire:+pilot-testing+a+psoriatic+arthritis+screening+and+evaluation+tool.">The PASE questionnaire: pilot-testing a psoriatic arthritis screening and evaluation tool.</a> Journal of the American Academy of Dermatology. 57 (4), 581-587 (2007).</li><li>Ibrahim, G. H., Buch, M. H., Lawson, C., Waxman, R., Helliwell, P. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+an+existing+screening+tool+for+psoriatic+arthritis+in+people+with+psoriasis+and+the+development+of+a+new+instrument:+the+Psoriasis+Epidemiology+Screening+Tool+(PEST)+questionnaire.">Evaluation of an existing screening tool for psoriatic arthritis in people with psoriasis and the development of a new instrument: the Psoriasis Epidemiology Screening Tool (PEST) questionnaire.</a> Clinical and Experimental Rheumatology. 27 (3), 469-474 (2009).</li><li>Walsh, J. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=PAPRIKA:+A+question+bank+for+assessing+psoriatic+arthritis+risk+in+individuals+of+diverse+ancestries.">PAPRIKA: A question bank for assessing psoriatic arthritis risk in individuals of diverse ancestries.</a> Arthritis Care &amp; Research. , (2023).</li><li>Feldman, S. R., Krueger, G. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Psoriasis+assessment+tools+in+clinical+trials.">Psoriasis assessment tools in clinical trials.</a> Annals of the Rheumatic Diseases. 64, 65-68 (2005).</li><li>McHugh, M. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interrater+reliability:+the+kappa+statistic.">Interrater reliability: the kappa statistic.</a> Biochemia Medica. 22 (3), 276-282 (2012).</li><li>Montes de Oca Pedrosa, A., Oakley, A., Rogers, J., Rangaitaha Epiha, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=PASI+vs+PO-PASI:+Patient-Oriented+PASI+(PO-PASI)+is+comparable+to+clinician+score+PASI.">PASI vs PO-PASI: Patient-Oriented PASI (PO-PASI) is comparable to clinician score PASI.</a> The Australasian Journal of Dermatology. 63 (1), e67-e70 (2022).</li></ol>

The PERCH software, for which B.-J.F. is the inventor, has been non-exclusively licensed to Ambry Genetics Corporation for its clinical genetic testing services and research. B-J.F. also reports funding and sponsorship to his institution on his behalf from Pfizer Inc., Regeneron Genetics Center LLC., and AstraZeneca. K.C.D. has consulted for Amgen/Celgene, Abbvie, Lilly, Novartis, Leo, Boehringer-Ingelheim, Janssen, UCB, CorEvitas, and Bristol-Myers Squib. The remaining authors declare no potential conflicts of interest relevant to this article.

Protocol step 1.4 is a crucial aspect of the proper construction of the Psoriasis Thickness Reference Card. To achieve an accurate representation of plaque thickness, it is imperative to avoid placing the tape vertically or flush against the vertical edge of the stack of sticky notes. If the tape is positioned in such a manner, the sharp edge of each stack will not mimic the feel of a psoriasis plaque. The tape should be applied in a way that creates a smooth slope connecting the stack to the paper.
Since the method is relatively simple, there are limited instances where modifications and troubleshooting might be necessary. If the sheet of printer paper is too flimsy, a piece of cardstock can be used as an alternative. Furthermore, in case the left sides of the stacks of sticky notes lose their adhesiveness, the left side of each stack may be taped to the paper using the same instructions as described in protocol step 1.4.
The main alternative method for induration scoring involves the physician assessing the patients&#39; induration severity. While this approach benefits from the expertise of a trained professional, it does require additional time during the visit, and it may not be practical for patients in remote locations. To address these challenges, the Psoriasis Thickness Reference Card offers a solution by empowering patients to conduct the induration assessment themselves before their clinic visit or even from the comfort of their home. This patient-driven approach provides a convenient and efficient means of monitoring induration severity. Moreover, research indicates that induration severity at its worst holds a greater predictive value for PsA than induration severity at the time of a clinical visit4. Therefore, frequent monitoring of psoriasis thickness by patients is more likely to yield data that are relevant for PsA prediction, enhancing the accuracy of the assessment and potentially leading to early detection and intervention.
Patients can utilize the card to assess the severity of induration in their psoriasis lesions, but it demonstrates only moderate concordance with the doctor&#39;s assessment. The cause of the discordance between patient and doctor assessments is not entirely clear.
A 2022 study found that a Patient-oriented Psoriasis Area and Severity Index had good interrater reliability and was positively correlated with the Psoriasis Area and Severity Index (PASI) as calculated by physicians. The present study did not include the percentage of body surface affected (BSA) and PASI. While BSA has been shown to be associated with PsA5,14, previous research demonstrates that induration is a stronger predictor4. Furthermore, both BSA and PASI are more challenging to measure, making them less suitable for patient self-assessment. As a result, BSA and PASI were not incorporated into the study.
In conclusion, the use of the Psoriasis Thickness Reference Card empowers psoriasis patients to independently measure the thickness of their psoriasis lesions. This approach can be utilized in a screening test to predict PsA development in individuals with cutaneous-only psoriasis. Advantages include simplicity, cost-effectiveness, and self-reliance, enabling convenient administration even for patients situated in remote locations. This approach has the potential to expand PsA risk assessment accessibility and reduce research costs related to psoriasis and PsA.

Psoriatic arthritis (PsA) is an inflammatory arthritis that develops in approximately 2.9% of patients with psoriasis each year1,2. Early prediction of which patients will develop PsA is crucial for a patient&#39;s quality of life as a diagnostic delay of as little as six months may cause irreversible damage to the joints3. A previous study had identified features associated with early-stage PsA. The three components of the Investigator&#39;s Global Assessment (IGA)-induration (thickness), erythema (redness), and desquamation (scaliness)-were highly correlated with each other and were nominally associated with subsequent PsA development. Multivariate analysis showed that a history of fingernail psoriasis and untreated induration of psoriasis lesions were independent PsA predictors4. Other studies have also identified psoriasis severity as associated with psoriatic arthritis2,5,6. The collection of these clinical factors is likely to be important in future PsA screening.
Several PsA screening tests exist7,8,9,10, but they require physicians to conduct them. A questionnaire-based screening test that can be completed by patients without physician assistance is an ideal format because it will not burden the dermatology and primary care clinics. Previously, the authors described a questionnaire with images that depict different severities of erythema and desquamation in multiple skin tones11. However, the measurement of induration requires a reference card corresponding to various plaque severities, such as that developed by the National Psoriasis Foundation12. The reference card is characterized by multiple raised areas of varying elevations, each corresponding to a number representing induration severity. To assess a patient&#39;s psoriasis severity in terms of induration, the card user compares the thickest psoriasis patch on a patient&#39;s body to the elevated areas on the card.
However, distributing a reference card to psoriasis patients may not be the most efficient approach for reaching a broad audience, especially for patients located outside the USA and for online survey studies. For researchers and clinicians gathering induration self-assessments from numerous patients, an alternative option could involve creating a homemade induration card using inexpensive office supplies. For patients, creating a homemade device from inexpensive office supplies can be more cost-effective than purchasing commercially available alternatives. This protocol describes how to create the Psoriasis Thickness Reference Card, an induration reference card that psoriasis patients can feel to assess the severity of their psoriasis induration. The Card can be made with standard office supplies and is inexpensive to make.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Post-it Notes, 1 3/8 in x 1 7/8 in, Canary Yellow, 6 Pads/Pack</td>
			<td>3M</td>
			<td>00021200569029</td>
			<td>The smallest sized sticky notes (5.08 cm height x 5.08 cm width or 5.08 cm height x 3.81 cm width) work best with the printed template. The thickness of each sticky note should be between 0.09 and 0.1 mm; sticky notes from the brands Post-it, Pen+Gear, and Office Works meet these requirements.</td>
		</tr>
		<tr>
			<td>Printworks Printer and Copy Paper - 500 Pack - White</td>
			<td>Paris Corporation</td>
			<td>0009014600006</td>
			<td>Any brand of printer paper is acceptable; if recreating the template manually rather than printing, any brand of paper is acceptable.</td>
		</tr>
		<tr>
			<td>R</td>
			<td>http://www.r-project.org</td>
			<td></td>
			<td>The R programming language version 4.3.1 was used to analyze the data in this study.&#160;</td>
		</tr>
		<tr>
			<td>Scotch Magic Tape Dispensered Rolls</td>
			<td>3M</td>
			<td>00021200000041</td>
			<td>Any brand of smooth adhesive tape is acceptable; do not use tape with a coarse texture.</td>
		</tr>
	</tbody>
</table>

measuring psoriasis severity at home

Psoriasis plaque severity metrics, such as induration (thickness), erythema (redness), and desquamation (scaliness), are associated with the subsequent development of psoriatic arthritis (PsA) among cutaneous-only psoriasis patients (patients with skin or nail psoriasis but no psoriatic arthritis). These metrics can be used for PsA screening. However, a key challenge in PsA screening is to optimize accessibility and minimize costs for patients, while also reducing the burden on healthcare systems. Therefore, an ideal screening tool consists of questions that patients can answer without a physician's assistance. Although reference images can be used to help a patient self-assess erythema and desquamation severity, a patient would need a tactile induration reference card to self-assess induration severity. This protocol describes how to create an induration reference card, the Psoriasis Thickness Reference Card, as well as how to use it to assess lesion induration severity. Administration of reference images for erythema and desquamation and a Psoriasis Thickness Reference Card for induration to 27 psoriasis patients showed that patients were moderately successful at self-assessing the severity of these three metrics. These findings support the feasibility of a future PsA screening test that patients can complete without the need for physician assistance.

To validate whether patient assessments of desquamation, erythema, and induration are comparable to those of a dermatologist, 27 psoriasis patients at the University of Utah dermatology clinic were enlisted to complete a questionnaire about psoriasis severity at the time of the questionnaire&#39;s administration. Each participant was provided with a Psoriasis Thickness Reference Card along with the questionnaire. The dermatologist provided their independent assessment of the current status of each patient using the same measuring scales.
Psoriasis severity was categorized into two groups, mild versus moderate to severe. Grouping moderate and severe psoriasis aligns with the clinical management of psoriasis patients. For induration, moderate corresponds to 5-8 sticky notes and severe corresponds to 10-13 sticky notes. The accuracy of patients&#39; assessments of desquamation, erythema, and induration was evaluated by sensitivity (the test&#39;s ability to correctly identify an individual as having the disease) and specificity (the test&#39;s ability to correctly identify an individual as not having the disease) using the physician&#39;s assessments as the gold standard. The Wilcoxon signed-rank test was used to examine whether patient assessments of psoriasis severity differed significantly from those of the attending dermatologist. Cohen&#39;s kappa was used to evaluate whether the two assessments were comparable.
The results demonstrated that the patients&#39; and physician&#39;s answers to some questions regarding psoriasis severity are moderately to highly concordant (Figure 2 and Table 1). The numbers of physician-patient severity assessments with matching values were 23 (85.2%), 25 (92.6%), and 22 (84.6%) for desquamation, erythema, and induration (which was answered by 26 out of 27 participants), respectively. There was no significant difference between patient and physician reports of desquamation (p = 0.42), erythema (p &#62; 0.99), and induration (p &#62; 0.99) by the Wilcoxon signed-rank test. Sensitivity ranged from 0.83 to 0.93 and specificity from 0.77 to 0.92. Cohen&#39;s kappa values revealed at least some level of agreement between the physician and patient assessments of all three variables (kappa scores &#62; 0.69, p-values &#60; 0.000002). Using Cohen&#39;s kappa interpretations suggested by McHugh13, moderate agreement was observed between physician and patient measurements of desquamation and induration; physician and patient measurements of erythema exhibited strong agreement.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66065/66065fig01v2.jpg" /> 
Figure 1: Completed Psoriasis Thickness Reference Card. The number under each square in the card indicates the number of sticky notes in each stack. The stacks of sticky notes are attached to the paper using the adhesive side of the notes on the left and a piece of tape on the right. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66065/66065fig01largev2.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/66065/66065fig02.jpg" /> 
Figure 2: Proportions of patient assessments that matched or did not match physician assessments. Each patient rated the severity of their current psoriasis lesions based on three psoriatic features; the attending dermatologist also rated each patient&#39;s psoriasis severity on the same scale. Each of the three columns represents physician ratings; the width of each column represents the proportion of patients given that rating by the physician. Within each column, the different colors represent the proportion of those patients given a specific physician rating who were also given a specific patient rating, e.g. approximately 50% of the patients who were assessed as having severe erythema by a physician were self-assessed as having moderate erythema. (A) Desquamation, (B) erythema, and (C) induration. Abbreviation: NA = not applicable (patient did not provide an assessment). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66065/66065fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Desquamation&#160;</td>
			<td>Erythema&#160;</td>
			<td>Induration&#160;</td>
		</tr>
		<tr>
			<td>True positive*&#160;</td>
			<td>13&#160;</td>
			<td>14&#160;</td>
			<td>10&#160;</td>
		</tr>
		<tr>
			<td>False positive*&#160;</td>
			<td>3&#160;</td>
			<td>1&#160;</td>
			<td>2&#160;</td>
		</tr>
		<tr>
			<td>False negative*&#160;</td>
			<td>1&#160;</td>
			<td>1&#160;</td>
			<td>2&#160;</td>
		</tr>
		<tr>
			<td>True negative*&#160;</td>
			<td>10&#160;</td>
			<td>11&#160;</td>
			<td>12&#160;</td>
		</tr>
		<tr>
			<td>Sensitivity&#160;</td>
			<td>0.93&#160;</td>
			<td>0.93&#160;</td>
			<td>0.83&#160;</td>
		</tr>
		<tr>
			<td>Specificity&#160;</td>
			<td>0.77&#160;</td>
			<td>0.92&#160;</td>
			<td>0.86&#160;</td>
		</tr>
		<tr>
			<td>Accuracy&#160;</td>
			<td>0.85&#160;</td>
			<td>0.93&#160;</td>
			<td>0.85&#160;</td>
		</tr>
		<tr>
			<td>Wilcoxon signed rank test p-value&#160;</td>
			<td>0.42&#160;</td>
			<td>&#62;0.99&#160;</td>
			<td>&#62;0.99&#160;</td>
		</tr>
		<tr>
			<td>Cohen&#8217;s kappa value [95% CI]</td>
			<td>0.70 [0.43,0.97]</td>
			<td>0.85 [0.65,1.00]</td>
			<td>0.69 [0.41,0.97]</td>
		</tr>
		<tr>
			<td>Cohen&#8217;s kappa category&#160;</td>
			<td>Moderate&#160;</td>
			<td>Strong&#160;</td>
			<td>Moderate&#160;</td>
		</tr>
	</tbody>
</table>
Table 1: Predictive value, sensitivity, and specificity of patient psoriasis severity ratings. Physician ratings were treated as the true values to which the patient ratings were compared. *Positive is moderate to severe psoriasis; negative is mild to no psoriasis. Abbreviation: CI = confidence interval.
Supplemental Figure S1: Psoriasis thickness Reference Card template. The template may be printed and used to directly place the sticky notes on, or it may be used as a guide for numbering and placing sticky notes on a sheet of paper if no printer is available. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66065/66065_SupplementalFile (2).zip" target="_blank">Please click here to download this File.</a>

Read this Scientific Article Protocol about Measuring Psoriasis Severity at Home at JoVE.com

Author Spotlight: Self-Assessment Protocol for Predicting Psoriatic Arthritis in Psoriasis Patients

This paper details the creation of a Psoriasis Thickness Reference Card, enabling psoriasis patients to self-assess their psoriasis plaque thickness without the need for physician assistance. Additionally, the precision of self-assessment for psoriasis redness and scaliness by employing reference images depicting various skin tones is assessed.

Measuring Psoriasis Severity at Home

Psoriasis plaque severity metrics, such as induration (thickness), erythema (redness), and desquamation (scaliness), are associated with the subsequent ...

Nanyang Technological University

Research

JoVE Journal

Medicine

306 Views.  University of Utah School of Medicine. This paper details the creation of a Psoriasis Thickness Reference Card, enabling psoriasis patients to self-assess their psoriasis plaque thickness without the need for physician assistance. Additionally, the precision of self-assessment for psoriasis redness and scaliness by employing reference images depicting various skin tones is assessed.

Video: Author Spotlight: Self-Assessment Protocol for Predicting Psoriatic Arthritis in Psoriasis Patients

Orthotopic Xenografting of Human Luciferase-Tagged Malignant Peripheral Nerve Sheath Tumor Cells for in vivo Testing of Candidate Therapeutic Agents

Although in vitro screens are essential for the initial identification of candidate therapeutic agents, a rigorous assessment of the drug's ability to inhibit tumor growth must be performed in a suitable animal model. The type of animal model that is best for this purpose is a topic of intense discussion. Some evidence indicates that preclinical trials examining drug effects on tumors arising in transgenic mice are more predictive of clinical outcome1and so candidate therapeutic agents are often tested in these models. Unfortunately, transgenic models are not available for many tumor types. Further, transgenic models often have other limitations such as concerns as to how well the mouse tumor models its human counterpart, incomplete penetrance of the tumor phenotype and an inability to predict when tumors will develop.
Consequently, many investigators use xenograft models (human tumor cells grafted into immunodeficient mice) for preclinical trials if appropriate transgenic tumor models are not available. Even if transgenic models are available, they are often partnered with xenograft models as the latter facilitate rapid determination of therapeutic ranges. Further, this partnership allows a comparison of the effectiveness of the agent in transgenic tumors and genuine human tumor cells. Historically, xenografting has often been performed by injecting tumor cells subcutaneously (ectopic xenografts). This technique is rapid and reproducible, relatively inexpensive and allows continuous quantitation of tumor growth during the therapeutic period2. However, the subcutaneous space is not the normal microenvironment for most neoplasms and so results obtained with ectopic xenografting can be misleading due to factors such as an absence of organ-specific expression of host tissue and tumor genes. It has thus been strongly recommended that ectopic grafting studies be replaced or complemented by studies in which human tumor cells are grafted into their tissue of origin (orthotopic xenografting)2. Unfortunately, implementation of this recommendation is often thwarted by the fact that orthotopic xenografting methodologies have not yet been developed for many tumor types.
Malignant peripheral nerve sheath tumors (MPNSTs) are highly aggressive sarcomas that occur sporadically or in association with neurofibromatosis type 13and most commonly arise in the sciatic nerve4. Here we describe a technically straightforward method in which firefly luciferase-tagged human MPNST cells are orthopically xenografted into the sciatic nerve of immunodeficient mice. Our approach to assessing the success of the grafting procedure in individual animals and subsequent non-biased randomization into study groups is also discussed.

Orthotopic Xenografting of Human Luciferase-Tagged Malignant Peripheral Nerve Sheath Tumor Cells for in vivo Testing of Candidate Therapeutic Agents

A method for reliably grafting luciferase-tagged human malignant peripheral nerve sheath tumor cells into the sciatic nerve of immunodeficient mice is described. The use of bioluminescence imaging to demonstrate proper establishment of tumor grafts and criteria for random segregation of animals into study groups are also discussed.

Although in vitro screens are essential for the initial identification of candidate therapeutic agents, a rigorous assessment of the drug's ability to ...

Measuring the Strength of Mice

Kondziela7 devised the inverted screen test and published it in 1964. It is a test of muscle strength using all four limbs. Most normal mice easily score maximum on this task; it is a quick but insensitive gross screen, and the weights test described in this article will provide a finer measure of muscular strength.
There are also several strain gauge-based pieces of apparatus available commercially that will provide more graded data than the inverted screen test, but their cost may put them beyond the reach of many laboratories which do not specialize in strength testing. Hence in 2000 a cheap and simple apparatus was devised by the author. It consists of a series of chain links of increasing length, attached to a "fur collector" a ball of fine wire mesh sold for preventing limescale build up in hard water areas. An accidental observation revealed that mice could grip these very tightly, so they proved ideal as a grip point for a weight-lifting apparatus. A common fault with commercial strength meters is that the bar or other grip feature is not thin enough for mice to exert a maximum grip. As a general rule, the thinner the wire or bar, the better a mouse can grip with its small claws.
This is a pure test of strength, although as for any test motivational factors could potentially play a role. The use of scale collectors, however, seems to minimize motivational problems as the motivation appears to be very high for most normal young adult mice.

Deficits in muscular strength occur in many clinical conditions such as motor neuron disease. The inverted screen and weight lifting tests described here measure strength in mice almost exclusively, with minimal influence of factors such as coordination.

Kondziela7 devised the inverted screen test and published it in 1964. It is a test of muscle strength using all four limbs. Most normal mice easily score ...

The Goeckerman Regimen for the Treatment of Moderate to Severe Psoriasis

Psoriasis is a chronic, immune-mediated inflammatory skin disease affecting approximately 2-3% of the population. The Goeckerman regimen consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT). Goeckerman therapy is extremely effective and relatively safe for the treatment of psoriasis and for improving a patient's quality of life. In the following article, we present our protocol for the Goeckerman therapy that is utilized specifically at the University of California, San Francisco. This protocol details the preparation of supplies, administration of phototherapy and application of topical tar. This protocol also describes how to assess the patient daily, monitor for adverse effects (including pruritus and burning), and adjust the treatment based on the patient's response. Though it is one of the oldest therapies available for psoriasis, there is an absence of any published videos demonstrating the process in detail. The video is beneficial for healthcare providers who want to administer the therapy, for trainees who want to learn more about the process, and for prospective patients who want to undergo treatment for their cutaneous disease.

Psoriasis is a chronic, immune-mediated inflammatory skin disease. The Goeckerman regimen, formulated for the treatment of psoriasis, consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT). The following protocol is for the administration of Goeckerman therapy for the treatment of moderate-to-severe psoriasis.

Psoriasis is a  chronic, immune-mediated inflammatory skin disease affecting approximately 2-3%  of the population. The Goeckerman regimen consists of ...

Flexible Colonoscopy in Mice to Evaluate the Severity of Colitis and Colorectal Tumors Using a Validated Endoscopic Scoring System

The use of modern endoscopy for research purposes has greatly facilitated our understanding of gastrointestinal pathologies. In particular, experimental endoscopy has been highly useful for studies that require repeated assessments in a single laboratory animal, such as those evaluating mechanisms of chronic inflammatory bowel disease and the progression of colorectal cancer. However, the methods used across studies are highly variable. At least three endoscopic scoring systems have been published for murine colitis and published protocols for the assessment of colorectal tumors fail to address the presence of concomitant colonic inflammation. This study develops and validates a reproducible endoscopic scoring system that integrates evaluation of both inflammation and tumors simultaneously. This novel scoring system has three major components: 1) assessment of the extent and severity of colorectal inflammation (based on perianal findings, transparency of the wall, mucosal bleeding, and focal lesions), 2) quantitative recording of tumor lesions (grid map and bar graph), and 3) numerical sorting of clinical cases by their pathological and research relevance based on decimal units with assigned categories of observed lesions and endoscopic complications (decimal identifiers). The video and manuscript presented herein were prepared, following IACUC-approved protocols, to allow investigators to score their own experimental mice using a well-validated and highly reproducible endoscopic methodology, with the system option to differentiate distal from proximal endoscopic colitis (D-PECS).

Over the past few years, new generation endoscopes have emerged as important diagnostic research aids for evaluating murine colitis and colorectal tumors. We present herein a detailed protocol for endoscopic assessment of inflammation and colorectal tumors in mice, as well as a novel scoring system that uses decimal identifiers to document the endoscopic severity of colitis and colorectal tumors.

The use of modern endoscopy for research purposes has greatly facilitated our understanding of gastrointestinal pathologies. In particular, experimental ...

High-definition Fourier Transform Infrared (FT-IR) Spectroscopic Imaging of Human Tissue Sections towards Improving Pathology

High-definition Fourier Transform Infrared (FT-IR) spectroscopic imaging is an emerging approach to obtain detailed images that have associated biochemical information. FT-IR imaging of tissue is based on the principle that different regions of the mid-infrared are absorbed by different chemical bonds (e.g., C=O, C-H, N-H) within cells or tissue that can then be related to the presence and composition of biomolecules (e.g., lipids, DNA, glycogen, protein, collagen). In an FT-IR image, every pixel within the image comprises an entire Infrared (IR) spectrum that can give information on the biochemical status of the cells that can then be exploited for cell-type or disease-type classification. In this paper, we show: how to obtain IR images from human tissues using an FT-IR system, how to modify existing instrumentation to allow for high-definition imaging capabilities, and how to visualize FT-IR images. We then present some applications of FT-IR for pathology using the liver and kidney as examples. FT-IR imaging holds exciting applications in providing a novel route to obtain biochemical information from cells and tissue in an entirely label-free non-perturbing route towards giving new insight into biomolecular changes as part of disease processes. Additionally, this biochemical information can potentially allow for objective and automated analysis of certain aspects of disease diagnosis.

High-definition Fourier Transform Infrared FT-IR Spectroscopic Imaging of Human Tissue Sections towards Improving Pathology

Fourier Transform Infrared (FT-IR) spectroscopic imaging is a fast and label-free approach to obtain biochemical data sets of cells and tissues. Here, we demonstrate how to obtain high-definition FT-IR images of tissue sections towards improving disease diagnosis.

High-definition Fourier Transform Infrared (FT-IR) spectroscopic imaging is an emerging approach to obtain detailed images that have associated ...

Dynamic Contrast Enhanced Magnetic Resonance Imaging of an Orthotopic Pancreatic Cancer Mouse Model

Dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) has been limitedly used for orthotopic pancreatic tumor xenografts due to severe respiratory motion artifact in the abdominal area. Orthotopic tumor models offer advantages over subcutaneous ones, because those can reflect the primary tumor microenvironment affecting blood supply, neovascularization, and tumor cell invasion. We have recently established a protocol of DCE-MRI of orthotopic pancreatic tumor xenografts in mouse models by securing tumors with an orthogonally bent plastic board to prevent motion transfer from the chest region during imaging. The pressure by this board was localized on the abdominal area, and has not resulted in respiratory difficulty of the animals. This article demonstrates the detailed procedure of orthotopic pancreatic tumor modeling using small animals and DCE-MRI of the tumor xenografts. Quantification method of pharmacokinetic parameters in DCE-MRI is also introduced. The procedure described in this article will assist investigators to apply DCE-MRI for orthotopic gastrointestinal cancer mouse models.

The goal of this protocol is to apply dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) for orthotopic pancreatic tumor xenografts in mice. DCE-MRI is a non-invasive method to analyze microvasculature in a target tissue, and useful to assess vascular response in a tumor following a novel therapy.

Dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) has been limitedly used for orthotopic pancreatic tumor xenografts due to severe ...

Cardiac Magnetic Resonance Imaging at 7 Tesla

CMR at an ultra-high field (magnetic field strength B0&#160;&#8805; 7 Tesla) benefits from the signal-to-noise ratio (SNR) advantage inherent at higher magnetic field strengths and potentially provides improved signal contrast and spatial resolution. While promising results have been achieved, ultra-high field CMR is challenging due to energy deposition constraints and physical phenomena such as transmission field non-uniformities and magnetic field inhomogeneities. In addition, the magneto-hydrodynamic effect renders the synchronization of the data acquisition with the cardiac motion difficult. The challenges are currently addressed by explorations into novel magnetic resonance technology. If all impediments can be overcome, ultra-high field CMR may generate new opportunities for functional CMR, myocardial tissue characterization, microstructure imaging or metabolic imaging. Recognizing this potential, we show that multi-channel radio frequency (RF) coil technology tailored for CMR at 7 Tesla together with higher order B0 shimming and a backup signal for cardiac triggering facilitates high fidelity functional CMR. With the proposed setup, cardiac chamber quantification can be accomplished in examination times similar to those achieved at lower field strengths. To share this experience and to support the dissemination of this expertise, this work describes our setup and protocol tailored for functional CMR at 7 Tesla.

The sensitivity gain inherent to ultrahigh field magnetic resonance holds promise for high spatial resolution imaging of the heart. Here, we describe a protocol customized for functional cardiovascular magnetic resonance (CMR) at 7 Tesla using an advanced multi-channel radio-frequency coil, magnetic field shimming and a triggering concept.

CMR at an ultra-high field (magnetic field strength B0&#160;&#8805; 7 Tesla) benefits from the signal-to-noise ratio (SNR) advantage inherent at higher ...

Home-Based Transcranial Direct Current Stimulation Device Development: An Updated Protocol Used at Home in Healthy Subjects and Fibromyalgia Patients

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation (NIBS) method, which modulates the membrane potential of neurons in the cerebral cortex by a low-intensity direct current. tDCS is a low-cost technique with minimal adverse effects and easy application. This neurostimulation method has a promising future to improve pain therapy, treatment of neuropsychiatric disorders, and physical rehabilitation.
Current studies demonstrate the benefits of using tDCS over consecutive multiple sessions. However, the daily displacement to the specialized centers, travel costs, and disruptions to daily activities are some of the difficulties faced by patients. Thus, to be more comfortable, easy-to-use, and not disrupt daily commitments, a home-based tDCS was designed. Therefore, the objective of this study was to evaluate the feasibility of a portable tDCS device for home use in healthy subjects and fibromyalgia patients.
Despite increased tDCS use and a reasonably large body of research on the effects across a range of clinical conditions, there is a limited amount of research on developing secure devices that guarantee the dose and contain a block system to avoid excessive use. Therefore, we used a tDCS device with a security system to permit daily use for 20 minutes with a minimal interval of 12 hours between sessions. A programmer preconfigures the equipment, which has a neoprene cap that allows the electrode positions in any assembly, according to individualized protocols for treatments or research. After, researchers can assess the effectiveness of treatment, and its adherence using information kept in the device software.
Results suggest that the device is feasible for home use, with proper monitoring of adherence and contact impedance. There were reports of a few adverse effects, which do not differ from those reported in the literature in studies with the treatment under direct supervision.

This study provides an updated home-based tDCS protocol that enables subjects to receive the beneficial effects of tDCS at home with an easy to use device with settings to control the use and dosage, enhancing the feasibility for long-term use at home.

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation (NIBS) method, which modulates the membrane potential of neurons in the ...

Multi-Modal Home Sleep Monitoring in Older Adults

The gold standard for sleep monitoring is attended in-lab polysomnography; however, this method may be cost-prohibitive and inconvenient for patients and research participants. Home sleep testing has gained momentum in the field of sleep medicine due to its convenience and lower cost, as well as being more naturalistic. The accuracy and quality of home sleep testing, however, may be variable because studies are not monitored by sleep technologists. There has been some success in improving the accuracy of home sleep studies by having trained sleep technicians assist participants inside their homes with putting on the devices, but this can be intrusive and time-consuming for those involved. In this protocol, participants undergo at-home sleep monitoring with multiple devices: 1) a single-channel EEG device; 2) a home sleep test for sleep-disordered breathing and periodic limb movements; 3) actigraphy; and 4) sleep logs. A major challenge of this study is obtaining high-quality sleep monitoring data on the first attempt in order to minimize participant burden. This protocol describes the implementation of educational manuals with step-by-step instructions and photos. The goal is to improve the quality of home sleep testing.

Here, we present a protocol to improve the quality of data from home sleep testing by providing a method to enhance instructions through a structured participant visit. This protocol includes the implementation of a step-by-step educational manual with photos to ensure proper placement of equipment.

The gold standard for sleep monitoring is attended in-lab polysomnography; however, this method may be cost-prohibitive and inconvenient for patients and ...

A Rat Carotid Artery Pressure-Controlled Segmental Balloon Injury with Periadventitial Therapeutic Application

Cardiovascular disease remains the leading cause of death and disability worldwide, in part due to atherosclerosis. Atherosclerotic plaque narrows the luminal surface area in arteries thereby reducing adequate blood flow to organs and distal tissues. Clinically, revascularization procedures such as balloon angioplasty with or without stent placement aim to restore blood flow. Although these procedures reestablish blood flow by reducing plaque burden, they damage the vessel wall, which initiates the arterial healing response. The prolonged healing response causes arterial restenosis, or re-narrowing, ultimately limiting the long-term success of these revascularization procedures. Therefore, preclinical animal models are integral for analyzing the pathophysiological mechanisms driving restenosis, and provide the opportunity to test novel therapeutic strategies. Murine models are cheaper and easier to operate on than large animal models. Balloon or wire injury are the two commonly accepted injury modalities used in murine models. Balloon injury models in particular mimic the clinical angioplasty procedure and cause adequate damage to the artery for the development of restenosis. Herein we describe the surgical details for performing and histologically analyzing the modified, pressure-controlled rat carotid artery balloon injury model. Additionally, this protocol highlights how local periadventitial application of therapeutics can be used to inhibit neointimal hyperplasia. Lastly, we present light sheet fluorescence microscopy as a novel approach for imaging and visualizing the arterial injury in three-dimensions.

The rat carotid artery balloon injury mimics the clinical angioplasty procedure performed to restore blood flow in atherosclerotic vessels. This model induces the arterial injury response by distending the arterial wall, and denuding the intimal layer of endothelial cells, ultimately causing remodeling and an intimal hyperplastic response.

Cardiovascular disease remains the leading cause of death and disability worldwide, in part due to atherosclerosis. Atherosclerotic plaque narrows the ...